37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 660710 |
Time | |
Date | 200506 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician oversight : supervisor |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 46 |
ASRS Report | 660710 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : leveling and steering warning |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : unqualified personnel performance deficiency : testing performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Chart Or Publication Company |
Primary Problem | Maintenance Human Performance |
Narrative:
During a maintenance check on aircraft inspection; I found a hydraulic tubing support on the l-hand wing main landing gear; reference ipc 32-53-11-06 to be defective and needed to be replaced. This tubing support; supports all the #1; #2; #3 and #4 brake hydraulic hoses; the leveling and steering hydraulic hoses on the inboard (body) main landing gear. The maintenance mechanics replaced the damaged part according to the srm 51-40-02; ipc 32-11-06 and maintenance manual 29-11-00 -- the regular leak checks were accomplished. The items were signed and by-back by a maintenance supervisor as the mechanic that performed the job is an unlicensed mechanic. I personally checked as an inspector and the item was finalized as a good repair. After the second flight; the flight crews started to obtain different light indications of aircraft leveling and steering system problems. Finally; in another station the aircraft was put on jacks and the landing gear were swing tested. When the gear was swung; they found out that the 2 hoses crossed (the leveling cylinder hydraulic line and the steering cylinders return hydraulic hose) on the item that had been previously replaced. The main cause was that there were 2 mechanics working on the same item -- one doing the removal and another mechanic doing the installation and that there was no communication between them. And that the system installation was not properly checked by the maintenance supervisor according to the maintenance procedures.
Original NASA ASRS Text
Title: A B747-400 HAD A TUBING SUPPORT FITTING REPLACED DURING A MAINT CHK BY A CONTRACT VENDOR. DURING FLT OPS; CREWS RPTED ACFT LEVELING AND STEERING PROBS. FOUND 2 HYD HOSES CROSSED.
Narrative: DURING A MAINT CHK ON ACFT INSPECTION; I FOUND A HYD TUBING SUPPORT ON THE L-HAND WING MAIN LNDG GEAR; REF IPC 32-53-11-06 TO BE DEFECTIVE AND NEEDED TO BE REPLACED. THIS TUBING SUPPORT; SUPPORTS ALL THE #1; #2; #3 AND #4 BRAKE HYD HOSES; THE LEVELING AND STEERING HYD HOSES ON THE INBOARD (BODY) MAIN LNDG GEAR. THE MAINT MECHS REPLACED THE DAMAGED PART ACCORDING TO THE SRM 51-40-02; IPC 32-11-06 AND MAINT MANUAL 29-11-00 -- THE REGULAR LEAK CHKS WERE ACCOMPLISHED. THE ITEMS WERE SIGNED AND BY-BACK BY A MAINT SUPVR AS THE MECH THAT PERFORMED THE JOB IS AN UNLICENSED MECH. I PERSONALLY CHKED AS AN INSPECTOR AND THE ITEM WAS FINALIZED AS A GOOD REPAIR. AFTER THE SECOND FLT; THE FLT CREWS STARTED TO OBTAIN DIFFERENT LIGHT INDICATIONS OF ACFT LEVELING AND STEERING SYS PROBS. FINALLY; IN ANOTHER STATION THE ACFT WAS PUT ON JACKS AND THE LNDG GEAR WERE SWING TESTED. WHEN THE GEAR WAS SWUNG; THEY FOUND OUT THAT THE 2 HOSES CROSSED (THE LEVELING CYLINDER HYD LINE AND THE STEERING CYLINDERS RETURN HYD HOSE) ON THE ITEM THAT HAD BEEN PREVIOUSLY REPLACED. THE MAIN CAUSE WAS THAT THERE WERE 2 MECHS WORKING ON THE SAME ITEM -- ONE DOING THE REMOVAL AND ANOTHER MECH DOING THE INSTALLATION AND THAT THERE WAS NO COM BTWN THEM. AND THAT THE SYS INSTALLATION WAS NOT PROPERLY CHKED BY THE MAINT SUPVR ACCORDING TO THE MAINT PROCS.
Data retrieved from NASA's ASRS site as of January 2009 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.